A group of brain surgeons is suing Blue Cross Blue Shield of Puerto Rico for allegedly withholding nearly $900,000 for surgeries at Westchester Medical Center for one of its subscribers injured in a motorcycle accident.
Brain & Spine Surgeons of New York accused Blue Cross of unjust enrichment in a complaint filed Oct. 20 in U.S. District Court, White Plains.
The patient, who is identified by the initials I.F., was injured on Aug. 18, 2016 while riding a motorcycle that struck a car. I.F. was taken to the E.R. at Westchester Medical Center in Valhalla.
Harrison-based Brain & Spine Surgeons was the hospital”™s on-call neurological specialist.
I.F.”™s neck was fractured at the C2 vertebrae and the spinal cord was severely compressed, according to the complaint. Immediate surgery was necessary.
Patients who arrive at an emergency room are entitled to appropriate medical screening and treatment under federal and state laws, the complaint states, “without inquiry into the individual”™s method of payment or insurance status.”
Doctors who violate the laws can be fined up to $50,000, according to the complaint, and imprisoned for up to a year.
I.F., who lives in Westchester, had health insurance from Triple-S Salud Inc., a San Juan, Puerto Rico Blue Cross insurer that boasts on its website, “We take care of you wherever you are and whenever you need it.”
Brain & Spine Surgeons is not one of the Puerto Rican Blue Cross”™s medical providers.
But the Puerto Rican insurer is part of the national Blue Care Blue Cross network, and the services its subscribers receive in New York are administered by Empire Blue Cross Blue Shield.
Brain & Spine Surgeons says that Blue Cross must pay the “prevailing rates” for out-of-network services.
I.F. needed two complex surgeries that cost $893,184. Blue Cross paid $17,815, leaving a balance of $875,369.
Blue Cross “received an unjustified windfall,” the complaint states, by withholding funds that should have been paid to the surgeons.
Blue Cross of Puerto Rico did not provide its side of the story in response to an email asking for comment on the allegations.
Brain & Spine Surgeons is represented by New Jersey attorney Michael F. Fried and Florida attorney Genevieve Lee Turner.
